55 year old female with septic shock


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Vignatha 

roll no: 55

I've been given this case to solve in an attempt to understand the topic of "patient clinical data analysis" to develop my competency in reading and comprehending clinical data including history, clinical findings, investigations, and come up with a diagnosis and treatment plan.

Following is the view of my case: 

A 55 year old female who is an agricultural labourer came to the casualty with chief complaints of no urine output since one day.

History of present illness:

Patient was apparently asymptomatic 2 days back then she had 10 episodes of vomiting which was non bilious, non projectile and with food as content, and history of loose stools.

She went to a local RMP in the next morning and there she was given IV fluids. She was alright and returned home.

But since one day she complaints of anuria,SOB and abdominal distension.


Past history:

Known case of hypertension since 8 years 

9 years ago she had a history of right lower limb swelling 

Which was associated with fever.

She had similar complaints 9 months back for which she went to hospital and got treated.

Personal history:

Diet:vegetarian 

Appetite:normal

Sleep:adequate 

Bowel and bladder movements:

Addictions: drinks toddy occasionally (once in 2 months)

Daily routine:

She was an active 55 year old agricultural labourer who used to wake up at 4am in the morning and finishes off her household works by 9 am and goes to field after having her breakfast. She returns home by 6pm and and sleeps at 9pm. She eats rice and curry for breakfast, lunch and dinner everyday.

General examination:

Patient is conscious, coherent and cooperative 

Pallor

No Icterus 

No Cyanosis

No Clubbing

No Lymphadenopathy 

Edema present








Systemic examination 

CVS: s1 s2 present 

          No murmurs 

RS: bilateral air entry present 

       Normal vesicular breath sounds heard 

PER ABDOMEN : distended 

CNS : patient is drowsy but arousable

INVESTIGATIONS 

23/1/23

RBS:124mg/dl

LFT

TOTAL BILIRUBIN:1.72

DIRECT BILIRUBIN:0.38

SGOT:88

SGPT:39

ALP:213

TOTAL PROTEINS:3.8

ALBUMIN:2.0

A/G:0.82

Phosphorus:6.2

Calcium:8.6

Serum creatinine:3.8

Serum uric acid:8.4

Serum magnesium:2.0

Sodium:139

Potassium:4.1

Chloride:100

Calcium ionized:0.83

                          Chest x ray (23/1/23)


Ecg on 22/1/23


Ecg on 23/1/23

Ecg on 24/1/23

Ecg on 25/1/23

Ecg on 26/1/23

Ecg on 28/1/23

Ecg on 31/1/23



PROVISIONAL DIAGNOSIS:


?septic encephalopathy ?uremic encephalopathy 

Septic shock with MODS(AKI,ALI) with multifocal atrial tachycardia (resolving) with right lower limb cellulitis with ? Pulmonary embolism with grade 2 bedsore s/p 4 sessions of hemodialysis done


Treatment:


IV fluids NS and RL @ 50ml/hr

Nebulisation with duolin 8th hrly, budecort and mucomist 12th hrly 

RT feeds 50ml free water 2nd hrly 

             50ml milk with protein powder 4th hrly 

Inj meropenem 500mg IV/BD (day2)

Inj pan 40 mg OD

Inj clindamycin 600mg IV TID (day7)

Inj lasix 40mg IV /BD 

Inj neomol 1gm iv sos(if temp >101F)

Inj heparin 5000IU iv BD

Tab metxl 12.5mg RT/OD

Tab shelcal po od

Tab pcm 650 mg po bd

Position change 4th hrly

Oint thrombophobe  gel for LA/BD

Right lower limb elevation and dressing 

B/l bed sore dressing 

Investigations on 

24/1/23                25/1/23        26/1/23           27/1/23

Hb:10.9                 10.2                10.2               9.5

TLC:20,200           13,000            10,300          8,300

RBC:4.30               3.79                3.81              3.59

PLT:1.78                1.4                   1.5                1.0

Urea:110                 146                 130                164

Creat:3.7                 4.8                   3.6                4.4

Sodium:145             126                 136                134

Potassium:3.9          3.2                   3.4                3.2

Chloride:103            92                    101               102


Investigations.       28/1/23.           29/1/23.         30/1/23

Hb                           8.6                                           8.3

TLC                        8,100                                       10,200

RBC                       3.23                                           3.1

PLT                         88,000                                      1.1

UREA                                                                      78

CREAT                                                                     3.2

SODIUM                                                                 134

POTASSIUM                                                           3.7

CHLORIDE.                                                            105


Investigations.       31/1/23.        1/2/23.     2/2/23.    3/2/23

Hb                            7.9               6.3            5.7         6.5

Tlc                           17,600          17,100    12,600   11,800

Rbc                         3.0                2.3             2.1         2.33

Plt                           1.4                 1.54          1.73        1.80

Urea                        91                  104           117        111

Creatinine               3.9                 4.6            5.1         5.3

Sodium                   133                136           135        135

Potassium                4.2                 4.5           4.2         3.7

Chloride                   1.03.             104           101.      99


Investigations.   4/2/23.       5/2/23    

Hb                      6.3             7.6

Tlc                      15,500       13,400

Rbc                     2.31          

Plt                       2.16           1.9

Urea                    127            69

Creatinine           6.0            4.0

Sodium              141           138

Potassium          3.9            3.3

Chloride             98             98





Bedsore on 25/1/23


Bedsore on 28/1/23



Bedsore on 1/2/23






Bedsore on 3/223







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